Changes in fat mass in stroke survivors: a systematic review

Effects of different exercise protocols on aerobic capacity, blood pressure, biochemical parameters, and body weight in chronic stroke survivors: a randomized controlled trial

OBJECTIVE

To explore the impact on risk factors for recurrent stroke after gait training among persons restricted in walking in the chronic phase after stroke.

METHODS

In this randomized controlled trial, two groups performed gait training, 1 session/day, 3 days/week for 6 weeks, including electromechanically assisted gait training on a treadmill (EAGT) (n=12) or variable conventional gait training only (n=15); a control group (n=11) continued as usual. Endurance assessed with the 6-minute walk test, blood pressure, weight and blood samples were collected at baseline and after 6 weeks. Total Cholesterol, High Density Lipoprotein Cholesterol, and Triglycerides in plasma, and HbA1c in blood (reflecting glucose levels) were analysed.

RESULTS

The EAGT group walked more than twice the distance compared to the Conventional training group while the effective training time was similar. Endurance in walking increased most in the Conventional group while the Control group declined. Systolic blood pressure decreased most in the Conventional group, with a moderate effect size (ŋp2) of 0.0921 (95% confidence interval (CI)0.0012-0.2598). Body weight decreased most in the EAGT group with a large effect size (ŋp2) of 0.1406 (95% CI0.0047-0.3452). Lipid levels exhibited non-conclusive changes and HbA1c did not change significantly in any group.

CONCLUSIONS

Results indicate that six weeks of gait training may change risk factors for recurrent stroke even in persons restricted in mobility and that different training methods may have differential effects. These findings are in agreement with previous studies in less severely disabled persons and should encourage further studies in the current subgroup.

Pathophysiological changes of muscle after ischemic stroke: a secondary consequence of stroke injury

Sufficient clinical evidence suggests that the damage caused by ischemic stroke to the body occurs not only in the acute phase but also during the recovery period, and that the latter has a greater impact on the long-term prognosis of the patient. However, current stroke studies have typically focused only on lesions in the central nervous system, ignoring secondary damage caused by this disease. Such a phenomenon arises from the slow progress of pathophysiological studies examining the central nervous system. Further, the appropriate therapeutic time window and benefits of thrombolytic therapy are still controversial, leading scholars to explore more pragmatic intervention strategies. As treatment measures targeting limb symptoms can greatly improve a patient's quality of life, they have become a critical intervention strategy. As the most vital component of the limbs, skeletal muscles have become potential points of concern. Despite this, to the best of our knowledge, there are no comprehensive reviews of pathophysiological changes and potential treatments for post-stroke skeletal muscle. The current review seeks to fill a gap in the current understanding of the pathological processes and mechanisms of muscle wasting atrophy, inflammation, neuroregeneration, mitochondrial changes, and nutritional dysregulation in stroke survivors. In addition, the challenges, as well as the optional solutions for individualized rehabilitation programs for stroke patients based on motor function are discussed.

High-Intensity Interval Training Improves Physical Function, Prevents Muscle Loss, and Modulates Macrophage-Mediated Inflammation in Skeletal Muscle of Cerebral Ischemic Mice

Although skeletal muscle is the main effector organ largely accounting for disability after stroke, considerably less attention is paid to the secondary abnormalities of stroke-related skeletal muscle loss. It is necessary to explore the mechanism of muscle atrophy after stroke and further develop effective rehabilitation strategy. Here, we evaluated the effects of high-intensity interval (HIIT) versus moderate-intensity aerobic training (MOD) on physical function, muscle mass, and stroke-related gene expression profile of skeletal muscle. After the model of middle cerebral artery occlusion (MCAO) was successfully made, the blood lactate threshold corresponding speed (S_LT) and maximum speed (S_max) were measured. Different intensity training protocols (MOD < S_LT; S_LT < HIIT < S_max) were carried out for 3 weeks beginning at 7 days after MCAO in the MOD and HIIT groups, respectively. We found that both HIIT and MOD prevented stroke-related gastrocnemius muscle mass loss in MCAO mice. HIIT was more beneficial than MOD for improvements in muscle strength, motor coordination, walking competency, and cardiorespiratory fitness. Furthermore, HIIT was superior to MOD in terms of reducing lipid accumulation, levels of IL-1β and IL-6 in paretic gastrocnemius, and improving peripheral blood CD4+/CD8+ T cell ratio, level of IL-10. Additionally, RNA-seq analysis revealed that the differentially expressed genes among HIIT, MOD, and MCAO groups were highly associated with signaling pathways involved in inflammatory response, more specifically the I-kappaB kinase/NF-kappaB signaling. Following the outcome, we further investigated the infiltrating immune cells abundant in paretic muscles. The results showed that HIIT modulated macrophage activation by downregulating CD86+ (M1 type) macrophages and upregulating CD163+ (M2 type) macrophages via inhibiting the TLR4/MyD88/NFκB signaling pathway and exerting an anti-inflammatory effect in paretic skeletal muscle. It is expected that these data will provide novel insights into the mechanisms and potential targets underlying muscle wasting in stroke.

Potential effects on cardiometabolic risk factors and body composition by short message service (SMS)-guided training after recent minor stroke or transient ischaemic attack: post hoc analyses of the STROKEWALK randomised controlled trial

OBJECTIVES

To evaluate effects of mobile phone text-messaging exercise instructions on body composition, cardiometabolic risk markers and self-reported health at 3 months after stroke.

DESIGN

Randomised controlled intervention study with per-protocol analyses.

SETTING

University Hospital in Sweden.

PARTICIPANTS

Seventy-nine patients (mean (SD) age 64 (10) years, 37% female) ≥18 years with good motor function (modified Rankin Scale ≤2) and capable to perform 6 min walking test at hospital discharge were randomised to either intervention (n=40) or control group (n=39). Key exclusion criteria: subarachnoid bleeding, uncontrolled hypertension, severe psychiatric problems or cognitive limitations.

INTERVENTIONS

The intervention group received beyond standard care, daily mobile phone instructional text messages to perform regular outdoor walking and functional leg exercises. The control group received standard care.

MAIN OUTCOME MEASURES

Fat mass and fat-free mass were estimated by bioelectric impedance analysis. Cardiometabolic risk factors like blood lipids, glycated haemoglobin and blood glucose were analysed at baseline and after 3 months.

RESULTS

Both groups changed favourably in fat-free mass (1.83 kg, 95% CI 0.77 to 2.89; p=0.01, effect size (ES)=0.63 vs 1.22 kg, 95% CI 0.39 to 2.0; p=0.05, ES=0.54) and fat mass (-1.30 kg, 95% CI -2.45 to -0.14; p=0.029, ES=0.41 vs -0.76 kg, 95% CI -1.74 to 0.22; p=0.123, ES=0.28). Also, many cholesterol related biomarkers improved; for example, total cholesterol -0.65 mmol/L, 95% CI -1.10 to -0.2; p=0.06, ES: 0.5 vs -1.1 mmol/L, 95% CI -1.47 to -0.56; p>0.001, ES=0.8. However, there were no between-group differences. At 3 months, 94% and 86%, respectively, reported very good/fairly good health in the text messaging and control groups.

CONCLUSIONS

No clear effect of 3 months daily mobile phone delivered training instructions was detected on body composition, cardiovascular biochemical risk factors or self-perceived health. Further research is needed to evaluate secondary prevention efforts in larger populations after recent stroke.

TRIAL REGISTRATION NUMBER

NCT02902367.

Sarcopenia in patients following stroke: an overlooked problem

Our aim was to investigate the prevalence of sarcopenia in stroke patients, the relationship between sarcopenia detected with different low muscle mass (LMM) adjustment methods, and between stroke-related parameters. Eighty-one patients with chronic stroke who underwent inpatient rehabilitation were included. Spasticity was evaluated by modified Ashworth scale, Brunnstrom staging approach was used for motor function evaluation, physical independence was evaluated using Barthel Index, quality-of-life was evaluated by EQ-5D-3L, and the Cumulative Illness Rating Scale was used to measure multimorbidity. Muscle strength was evaluated by handgrip strength, muscle quantity through a bioelectric impedance analysis, and physical performance by gait speed and short physical performance battery. LMM was calculated through two different methods: Skeletal muscle mass (SMM)/height2, and SMM/BMI. For the definition of sarcopenia, we followed the EWGSOP2 recommendation. Associated sarcopenia factors were predicted by multivariate binary logistic regression analysis. The prevalence of probable sarcopenia was 32.1%. The prevalence of confirmed/sarcopenia when LMM was adjusted for BMI was higher than when adjusted for height2 (16 and 1.2%, respectively). Age was significantly higher in those with probable sarcopenia (P = 0.006). Stroke duration was shorter in those with probable or confirmed sarcopenia (P = 0.004, P < 0.001, respectively). EQ-5D-3L scores were significantly lower in those with confirmed sarcopenia (P = 0.050). The strongest associated factor with confirmed sarcopenia was stroke duration (OR: 0.77; 95% CI, 0.618-0.965). This study suggests that prevalence of sarcopenia after a stroke is significantly high. LMM adjusted for BMI comes in front as the adjustment method for LMM after a stroke.

Measuring and Monitoring Skeletal Muscle Mass after Stroke: A Review of Current Methods and Clinical Applications

OBJECTIVES

Muscle mass at admission is important to survive stroke, and stroke-induced sarcopenia is a serious problem because of its poor prognosis. Muscle mass measurement and monitoring are essential for appropriate rehabilitation and nutrition management. However, few reviews are available about the muscle mass measurement and monitoring after stroke.

MATERIAL AND METHODS

Several methods are used to assess skeletal muscle mass in stroke, such as computed tomography (CT), ultrasound, bioelectrical impedance analysis, dual-energy X-ray absorptiometry, biomarkers, and anthropometrics. We summarized the current methods and clinical applications in stroke.

RESULTS

In stroke, a head CT is used to estimate muscle mass by measuring the temporal muscle. However, it can be conducted retrospectively due to radiation exposure. After stroke, limb muscle atrophy and diaphragm dysfunction are observed using ultrasound. However, ultrasound requires an understanding of the methods and skill. A bioelectrical impedance analysis can be used to assess muscle mass in patients after a stroke unless they have dynamic fluid changes. Dual-energy X-ray absorptiometry is used for follow-up after hospital discharge. Urinary titin N-fragment and serum C-terminal agrin fragment reflect muscle atrophy after stroke. Anthropometrics may be useful with limited resources.

CONCLUSIONS

We summarized the features of each measurement and proved the recent evidence to properly measure and monitor skeletal muscle mass after stroke.

Sarcopenic Obesity and Activities of Daily Living in Stroke Rehabilitation Patients: A Cross-Sectional Study

Reports investigating the relationship between sarcopenic obesity and activities of daily living in older patients with stroke were limited. This study aimed to examine the prevalence of sarcopenic obesity and its association with activities of daily living in older post-stroke patients in convalescent rehabilitation wards. This study was performed in older post-stroke patients admitted to convalescent rehabilitation wards between January 2017 and March 2019. Sarcopenia was diagnosed based on the skeletal muscle mass index and hand grip strength according to the criteria of the 2019 Asian Working Group for Sarcopenia. Obesity was diagnosed according to the body fat percentage; ≥27% in men, ≥38% in women. The primary outcome was the Functional Independence Measure (FIM) score upon admission, which was analyzed using multiple linear regression. In total, 376 participants (women 44%; mean age 77.5 years) were analyzed and classified as normal (22%), simple obesity (17%), sarcopenia without obesity (32%), and sarcopenic obesity (28%). The presence of sarcopenic obesity was independently associated with the FIM score (95% CI, -16.157 to -5.353), whereas simple obesity and sarcopenia without obesity were not. In conclusion, sarcopenic obesity was independently associated with lower activities of daily living capability in older patients with stroke.

Effect of Post-Stroke Rehabilitation on Body Mass Composition in Relation to Socio-Demographic and Clinical Factors

Background and objectives: Stroke is one of the leading causes of morbidity, mortality and long-term adult disability. The aim of this study was to assess the changes in body mass composition in patients after stroke in connection with selected socio-demographic and clinical factors (sex, age, type of stroke and time from the first symptoms) following the rehabilitation process. Materials and Methods: The study group consisted of 100 post-stroke subjects who participated in a comprehensive rehabilitation program for a duration of five weeks. The measurements of body composition by a Tanita MC 780 MA analyser were performed on the day of admission to hospital, on the day of discharge (after 5 weeks) and 12 weeks after discharge from hospital. Results: It was shown that before rehabilitation (Exam I) in the study group there were significant differences in body composition relative to sex, age and time from stroke. The rates of fat mass % and visceral fat level decreased after rehabilitation (Exam II) in both males and females. Exam II, at the end hospital rehabilitation, showed lower levels of fat mass %, visceral fat level, as well as fat-free mass % and higher values of total body water % and muscle mass %. In Exam III, i.e., 12 weeks after discharge, all of the parameters retained their values. Conclusions: The study shows an association between stroke risk factors (primarily age, sex and time from the onset of the first symptoms of stroke) and body mass composition resulting from rehabilitation. The type of stroke and the effects of rehabilitation on body mass components showed no differences. Comprehensive rehabilitation had a positive effect on the body mass components.

Resistance training in stroke rehabilitation: systematic review and meta-analysis

Objective:

This systematic review and meta-analysis investigates the effects of resistance training in supporting the recovery in stroke patients.

Data sources:

PubMed, the Cochrane Central Register of Controlled Trials and the PEDro databases were reviewed up to 30 April 2020.

Review methods:

Randomized controlled trials were included, who compared: (i) resistance training with no intervention, (ii) resistance training with other interventions and (iii) different resistance training protocols in stroke rehabilitation.

Results:

Overall 30 trials ( n = 1051) were enrolled. The parameters evaluated were: (1) gait, (2) muscular force and motor function, (3) mobility, balance and postural control, (4) health related quality of life, independence and reintegration, (5) spasticity and hypertonia, (6) cardiorespiratory fitness, (7) cognitive abilities and emotional state and (8) other health-relevant physiological indicators. The data indicates that: (i) resistance training is beneficial for the majority of parameters observed, (ii) resistance training is superior to other therapies on muscular force and motor function of lower and upper limbs, health related quality of life, independence and reintegration and other health-relevant physiological indicators, not significantly different from other therapies on walking ability, mobility balance and postural control and spasticity and hypertonia, and inferior to ergometer training on cardiorespiratory fitness and (iii) the type of resistance training protocol significantly impacts its effect; leg press is more efficient than knee extension and high intensity training is superior than low intensity training.

Conclusion:

Current data indicates that resistance training may be beneficial in supporting the recovery of stroke patients. However, the current evidence is insufficient for evidence-based rehabilitation.

Effects of stroke injury on the shear modulus of the lower leg muscle during passive dorsiflexion

Contractures are common complications of a stroke. The spatial location of the increased stiffness among plantar flexors and its variability among survivors remain unknown. This study assessed the mechanical properties of the lower leg muscles in stroke survivors during passive dorsiflexions. Stiffness was estimated through the measurement of the shear modulus. Two experiments were independently conducted, in which participants lay supine: with the knee extended ( experiment 1, n = 13 stroke survivors and n = 13 controls), or with the knee flexed at 90° ( experiment 2, n = 14 stroke survivors and n = 14 controls). The shear modulus of plantar flexors [gastrocnemius medialis (three locations), gastrocnemius lateralis (three locations), soleus (two locations), flexor digitorum longus, flexor hallucis longus), peroneus longus] and dorsiflexors (tibialis anterior and extensor digitorum longus) was measured using ultrasound shear wave elastography during passive dorsiflexions (2°/s). At the same ankle angle, stroke survivors displayed higher shear modulus than controls for gastrocnemius medialis and gastrocnemius lateralis (knee extended) and soleus (knee flexed). Very low shear modulus was found for the other muscles. The adjustment for muscle slack angle suggested that the increased shear modulus was arising from consequences of contractures. The stiffness distribution between muscles was consistent across participants with the highest shear modulus reported for the most distal regions of gastrocnemius medialis (knee extended) and soleus (knee flexed). These results provide a better appreciation of stiffness locations among plantar flexors of stroke survivors and can provide evidence for the implementation of clinical trials to evaluate targeted interventions applied on these specific muscle regions.

NEW & NOTEWORTHY The shear modulus of 13 muscle regions was assessed in stroke patients using elastography. When compared with controls, shear modulus was increased in the gastrocnemius muscle (GM) when the knee was extended and in the soleus (SOL) when the knee was flexed. The distal regions of GM and SOL were the most affected. These changes were consistent in all the stroke patients, suggesting that the regions are a potential source of the increase in joint stiffness.

Structural muscular adaptations in upper limb after stroke: a systematic review

BACKGROUND

Stroke is a leading cause of disability in the adult population, impairing upper limb (UL) movements affecting activities of daily living. Muscle weakness has been associated to disabilities in this population, but much attention is given to central nervous system alterations and less to skeletal muscles.

OBJECTIVE

The objective of this review is to carry out a systematic literature review to identify structural muscle alterations in the UL of poststroke individuals.

METHOD

The search was performed in December, 2017. MEDLINE, PubMed, SCOPUS, CINAHL, and Science Direct were used as electronic databases. There was no restriction regarding language and publication dates. Studies conducted on poststroke subjects and results on UL skeletal muscle alterations identified by imaging tests were included.

RESULTS

Seven studies were included. The sample size and the variables varied among the studies. All the studies compared the paretic UL with the nonparetic UL and one of the studies also compared healthy subjects. Ultrasonography was the most used measurement tool to assess muscle adaptation.

CONCLUSIONS

This review demonstrated little evidence with poor to fair quality on the structural muscle adaptations in the poststroke subjects, showing muscle atrophy, a higher stiffness, and amount of fibrous and fat tissue without alterations in lean tissue of distal muscles of the paretic UL compared to the nonparetic limb. However, the nonparetic side also presented alterations, which makes it an inappropriate comparison. Thus, well-designed studies addressing this issue are required.

Reducing sedentary time and fat mass may improve glucose tolerance and insulin sensitivity in adults surviving 6 months after stroke: A phase I pilot study

INTRODUCTION

Deranged glycaemic control is common post-stroke, increasing risks of recurrent stroke and development of diabetes. The aim of the study is to examine glucose metabolism in relation to body composition, physical activity and sedentary time post-stroke.

PATIENTS AND METHODS

Observational study: Non-diabetic adults, unable to walk independently, were recruited within 2 weeks of first stroke. Primary outcome: 2-h glucose level (mmol/l, oral glucose tolerance test), assessed at baseline and 6 months. Homeostasis Model Assessment of Insulin Sensitivity, total body fat and lean mass (dual energy X-ray absorptiometry), sedentary time (lying or sitting), standing and walking (PAL2 accelerometer) were assessed at baseline, 1, 3 and 6 months. Generalised estimating equations were used to examine change over time and associations between outcome measures.

RESULTS

Thirty-six participants (69.5 years (standard deviation 11.7), 13 (36.1%) female, moderate stroke severity (National Institute of Health Stroke Scale 11.5 (interquartile range 9.75, 16)). Within 6 months, adjusting for age and National Institute of Health Stroke Scale, every month 2-h glucose reduced by 4.5% (p < 0.001), Homeostasis Model Assessment of Insulin Sensitivity improved 3% (p = 0.04) and fat mass decreased 490 g (95% confidence interval 325, 655; p = 0.01). For every extra kilogram of body fat, 2-h glucose increased by 1.02 mmol/L (95% confidence interval 1.01, 1.02; p = 0.001); Homeostasis Model Assessment of Insulin Sensitivity reduced by 0.98% (95% confidence interval 0.97, 0.99; p = 0.001). Time spent sedentary reduced from 98.5% of measurement period (interquartile range 94.3, 99.8) to 74.3% (interquartile range 65.5, 88.6), by 2.8% monthly (95% confidence interval 1.8, 3.9, p < 0.001). For every additional 5% sedentary time, 2-h glucose increased by 1.05 mmol/L (95% confidence interval 1.04, 1.07; p < 0.001).

CONCLUSION

Reducing sedentary time and fat mass within 6 months of stroke may improve glucose tolerance and insulin resistance.

Functional performance, nutritional status, and body composition in ambulant community-dwelling individuals 1-3 years after suffering from a cerebral infarction or intracerebral bleeding

Background

Muscle wasting and obesity may complicate the post-stroke trajectory. We investigated the relationships between nutritional status, body composition, and mobility one to 3 years after stroke.

Methods

Among 279 eligible home-dwelling individuals who had suffered a stroke (except for subarachnoid bleeding) 1–3 years earlier, 134 (74 ± 5 years, 69 % men) were examined according to the Mini Nutritional Assessment-Short Form (MNA-SF, 0–14 points), including body mass index (BMI, kg/m²), body composition by bio-impedance analyses (Tanita BC-545), the Short Physical Performance Battery (SPPB, 0–12 points) combining walking speed, balance, and chair stand capacity, and the self-reported Physical Activity Scale for the Elderly (PASE).

Results

BMI ≥ 30 kg/m² was observed in 22 % of cases, and 14 % were at risk for malnutrition according to the MNA-SF. SPPB scores ≤ 8 in 28 % of cases indicated high risk for disability. Mobility based on the SPPB was not associated with the fat-free mass index (FFMI) or fat mass index (FMI). Multivariate logistic regression indicated that low mobility, i.e., SPPB ≤ 8 points, was independently related to risk for malnutrition (OR 4.3, CI 1.7–10.5, P = 0.02), low physical activity (PASE) (OR 6.5, CI 2.0–21.2, P = 0.02), and high age (OR 0.36, CI 0.15–0.85, P = 0.02). Sarcopenia, defined as a reduced FFMI combined with SPPB scores ≤ 8 or reduced gait speed (<1 m/s), was observed in 7 % of cases. None of the individuals displayed sarcopenic obesity (SO), defined as sarcopenia with BMI > 30 kg/m².

Conclusions

Nutritional disorders, i.e., obesity, sarcopenia, or risk for malnutrition, were observed in about one-third of individuals 1 year after stroke. Risk for malnutrition, self-reported physical activity, and age were related to mobility (SPPB), whereas fat-free mass (FFM) and fat mass (FM) were not. Nutrition and exercise treatment could be further evaluated as rehabilitation opportunities after stroke.

Reduced Resting Metabolic Rate in Adults with Hemiparetic Chronic Stroke

OBJECTIVE

Resting metabolic rate (RMR) is the component of energy expenditure that explains the largest proportion of total daily energy requirements. Since RMR is determined largely by fat-free mass and a low RMR predicts weight gain in healthy adults, identifying the role of muscle atrophy following stroke on RMR may help identify ways to mitigate the development of obesity post-stroke.

METHODS

Thirty-nine stroke survivors with chronic hemiparesis (mean ± SEM: age: 61 ± 1 years, latency from stroke: 107 ± 40 months, BMI: 31 ± 3 kg/m2) underwent DXA scans for measurement of body composition, including total, paretic, and non-paretic leg lean mass and fasted, 30-min indirect calorimetry for measurement of RMR.

RESULT

Predicted RMR was calculated by the Mifflin-St Jeor equation, which considers weight, height, and age for both men and women. RMR was 14% lower than predicted (1438 ± 45 vs. 1669 ± 38 kcals/24 hrs; P<0.01). Total (r=0.73, P<0.01), paretic (r=0.72, P<0.01) and non-paretic (r=0.67, P<0.01) leg lean mass predicted RMR.

CONCLUSION

These data indicate that muscle atrophy post stroke may lead to a reduced RMR. This substantiates the need to attenuate the loss of lean mass after a stroke to prevent declines in RMR and possible weight gain common post-stroke.

Investigation of changes in body composition, metabolic profile and skeletal muscle functional capacity in ischemic stroke patients: the rationale and design of the Body Size in Stroke Study (BoSSS)

BACKGROUND

Stroke is steadily increasing in prevalence. Muscle tissue wasting and functional changes are frequently observed in stroke, but this has not been studied in detail yet. There is a lack of data to support guideline recommendations on how to target muscle wasting in stroke patients. We hypothesise that pathophysiological metabolic profiles and muscle functional and structural impairment are developing in stroke patients, which are associated with stroke severity and outcome after stroke.

METHODS

The Body Size in Stroke Study (BoSSS) is a prospective, longitudinal observation study that will explore associations between the metabolic profile, body tissue wasting and particular metabolic and functional changes in skeletal muscle tissue in stroke patients. Consecutive patients with acute stroke (n = 150) will be enrolled due to lacunar or territorial ischemic infarct in the area of the middle cerebral artery. Patients will be studied at annual intervals after 12 and 24 months. For comparison, healthy controls of similar age and patients with chronic heart failure will be used as control groups. The main objective is to study changes in body composition in stroke patients. Secondary, the study will focus on changes in insulin sensitivity of adipose tissue and skeletal muscle. Furthermore, measurements of endothelial function and peripheral blood flow will provide insight in the vascular regulation in stroke patients.

CONCLUSION

This study will be the largest observational study providing insights into the metabolic and functional changes of muscle tissue in patients with acute ischemic stroke. The new data will increase our understanding of the pathophysiologic tissue wasting in stroke disease and help to develop new therapeutic strategies.